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Background: The importance of interpersonal behavior at the workplace is increasingly recognized in the health care industry and related literature. An unresolved issue in the existing health care research is how a climate of courteous interpersonal behavior may form the foundation for strong hospital care performance. Purpose: The aim of this study was to test the link between a climate of courteous interpersonal behavior, termed "civility climate," and hospital care performance. We conceptualize a multidimensional model of care performance by contrasting two dimensions: performance as perceived by employees and performance as perceived by patients. Furthermore, for both performance perspectives, we test an intermediate variable (error orientation climate) that may explain the relationship between civility climate and hospital care performance. Methodology: The 2011 study sample comprised responses from 6,094 nurses and 38,627 patients at 123 Veterans Health Administration acute care inpatient hospitals in the United States. We developed and empirically tested a theoretical model using regression modeling, and we used a bootstrap method to test for mediation. Results: The results indicate a direct effect of civility climate on employee perceptions of care performance and an indirect effect mediated by error orientation climate. With regard to patient perceptions of care performance, the analyses reveal a direct effect of civility climate. The indirect effect mediated by error orientation climate was not supported. Practice implications: Our findings point to the importance of strengthening interpersonal interactions for ensuring and improving both employees' and patients' perceptions of care, which constitute key success factors in the increasingly competitive hospital market. The insights may further stimulate discussion regarding interventions to foster a strong civility climate in hospitals.
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Let’s be civil: Elaborating the link
between civility climate and hospital
performance
Eva-Maria Oppel
David C. Mohr
Justin K. Benzer
Background: The importance of interpersonal behavior at the workplace is increasingly recognized in the health
care industry and related literature. An unresolved issue in the existing health care research is how a climate
of courteous interpersonal behavior may form the foundation for strong hospital care performance.
Purpose: The aim of this study was to test the link between a climate of courteous interpersonal behavior, termed
‘‘civility climate,’’ and hospital care performance. We conceptualize a multidimensional model of care performance by
contrasting two dimensions: performance as perceived by employees and performance as perceived by patients.
Furthermore, for both performance perspectives, we test an intermediate variable (error orientation climate) thatmay
explain the relationship between civility climate and hospital care performance.
Methodology: The 2011 study sample comprised responses from 6,094 nurses and 38,627 patients at 123 Veterans
Health Administration acute care inpatient hospitals in the United States. We developed and empirically tested a
theoretical model using regression modeling, and we used a bootstrap method to test for mediation.
Results: The results indicate a direct effect of civility climate on employee perceptions of care performance and an
indirect effect mediated by error orientation climate. With regard to patient perceptions of care performance, the
analyses reveal a direct effect of civility climate. The indirect effect mediated by error orientation climate was
not supported.
Practice Implications: Our findings point to the importance of strengthening interpersonal interactions for ensuring
and improving both employees’ and patients’ perceptions of care, which constitute key success factors in the
increasingly competitive hospital market. The insights may further stimulate discussion regarding interventions to
foster a strong civility climate in hospitals.
Key words: civility, error orientation, hospital, organizational climate, performance
Eva-Maria Oppel, PhD, Research Fellow at Department of Health Care Management, Universita¨t Hamburg, and Research Fellow at Hamburg
Center for Health Economics, Germany. E-mail: eva.oppel@uni-hamburg.de.
David C. Mohr, PhD, Investigator at Center for Healthcare, Organization and Implementation Research, VA Boston Healthcare System, and
Research Assistant Professor at Boston University School of Public Health, Massachusetts.
Justin K. Benzer, PhD, Implementation Science Core Chief, VISN 17 Center of Excellence for Research on Returning War Veterans, Central Texas
VA Healthcare System, Waco, and Associate Professor at Department of Psychiatry, Dell Medical School, University of Texas at Austin.
This material is based on work supported (or supported in part) by the Department of Veterans Affairs, Veterans Health Administration, Office of
Research and Development and Health Services Research and Development (IIR 08-067, CDA 11-246).
The views expressed in this article are those of the authors and do not necessarily reflect the position or policy of the Department of Veterans Affairs or
the United States government.
The authors have disclosed that they have no significant relationship with, or financial interest in, any commercial companies pertaining to this article.
DOI: 10.1097/HMR.0000000000000178
Health Care Manage Rev, 2017, 44(3), 00Y00
Copyright B2017 Wolters Kluwer Health, Inc. All rights reserved.
Month &2017 1
Copyright © 2017 Wolters Kluwer Health | Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
The work environment in which employees deliver
and patients receive hospital care is increasingly
recognizedas a key success factor in the health care
industry (e.g., McCaughey, McGhan, Walsh, Rathert, &
Belue, 2014; Rathert & May, 2007). In this context, the
construct of organizational climate has garnered a great deal
of attention in the health care literature (e.g., McFadden,
Stock, & Gowen, 2015; Richter, McAlearney, & Pennell,
2016; Singer et al., 2009). Organizational climate refers to
shared perceptions related to the policies, procedures, and
practices that govern behaviors in a specific area of interest.
Organizational climate has been characterized as founda-
tional or specific (Schneider, Ehrhart, & Macey, 2013).
Foundational climates are shared perceptions that reference
the broad workplace environment and can provide a sup-
portive foundation for specific climates to develop (Schneider
et al., 2013). Specific climates focus on specific types of
behaviors, such as customer service and safety. Despite
acknowledging that interpersonal interactions may be
important determinants of care performance (e.g., Gittell,
Godfrey, & Thistlethwaite, 2013; Wright & Khatri, 2015),
health care scholars have devoted scant attention to foun-
dational climates of courteous interpersonal behavior. Ad-
dressing this research gap, in this article, we develop a
conceptual framework for how civility climate, a founda-
tional climate that represents courteous interpersonal be-
havior (Leiter, Spence Laschinger, Day, & Oore, 2011;
Osatuke, Moore, Ward, Dyrenforth, & Belton, 2009), im-
pacts hospital care performance as measured by employee
and patient perceptions. Building on prior research, we
define civility climate as a shared perception of the extent
to which an organization rewards, supports, and expects (a)
respect and acceptance, (b) cooperation, (c) supportive rela-
tionships between coworkers, and (d) fair conflict resolu-
tion (Osatuke et al., 2009).
The purpose of the current study is to test a conceptual
framework that advances health care research in three ways.
First, adding to the growing, but limited, civility research in
health care, we investigate the link between civility climate,
a foundational climate, and care performance. Prior civility
research in the health care context has focused on the
evaluation of employee-based civility interventions and the
impact of civility on health care provider outcomes (Laschinger
& Read, 2016; Leiter et al., 2011; Osatuke et al., 2009).
McGonagle, Walsh, Kath, and Morrow (2014) provided
initial evidence on the association between civility norms
and workplace safety, such as unsafe worker behaviors and
injuries. While acknowledging this research for highlight-
ing the importance of civility in the health care context,
there remains limited knowledge on whether and how shared
perceptions of civil interactions at work affects perceptions
of care performance.
Second, the vast majority of empirical studies in the health
care context have related climate directly to organizational
outcomes, neglecting the ‘‘black box’’ of the processes in-
tervening between organizational climate and performance
(Hofmann & Mark, 2006; Singer et al., 2009). Reviewing
prior health care climate research, two streams emerge.
Foundational climate research, focusing on aspects related
to the psychosocial work environment or workplace bul-
lying, tend to focus on employee-related outcomes, such as
employee well-being (e.g., Rodwell, Demir, Parris, Steane,
& Noblet, 2012). Research focusing on specific climate
dimensions, such as safety climate, tends to focus on the
impact on patient outcomes (e.g., McFadden et al., 2015;
Singer et al., 2009). This fragmentation in existing research
limits our understanding of (a) the link between foun-
dational and specific climates and (b) mediating process
through which climate affects different dimensions of
performance in health care. In an attempt to address this
research gap, we combine foundational and specific cli-
mate research. Specifically, we test hypotheses regarding
how error orientation climate (i.e., a shared perception of
attitudinal and behavioral tendencies relevant to han-
dling and processing errors) might explain the link be-
tween civility climate and performance. Error orientation
is a key factor in safety climate, a specific climate, and
concerns desirable workplace attitudes and behaviors
that are pivotal for delivering high-quality health care
(Hofmann & Mark, 2006; Naveh & Katz-Navon, 2014).
Considering that medical errors are frequently related to
interactions within the hospital care team (Buljac-Samardºic,
Van Woerkom, & Paauwe, 2012), a shared perception of
error orientation is assumed to be particularly sensitive to
interpersonal aspects of the work environment (Naveh &
Katz-Navon, 2014), such as civility. Taking up on this evi-
dence, we conceive error orientation climate as an important
mediator in the civilityYperformance link. We posit that a
strong foundational civility climate is needed to promote
error orientation climate, which may explain how civility
climate affects care perceptions.
Third, addressing the need for multidimensionality in
performance measurement, we test a multidimensional
model of care performance by contrasting two performance
dimensions: performance as perceived by employees and
performance as perceived by patients. Acknowledging that
employees and patients might perceive different dimen-
sions of the performance construct (DiMatteo & DiNicola,
1981), patient perspectives are being increasingly incorpo-
rated into previously clinician-centric and organization-
centric performance theories (Rathert, Wyrwich, & Boren,
2013; Singer et al., 2011). Considering both performance
perspectives, we aim to add to civility research by investi-
gating whether a strong civility climate is not only ben-
eficial for employees but also for patients.
The conceptual model tested in this study is summarized
in Figure 1.
2Health Care Management Review Month &2017
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Conceptual Model and Research
Hypotheses
Civility Climate and Perceptions of
Care Performance
Care performance is multidimensional in part because em-
ployees and patients may perceive and value different types
of care performance behaviors. Prior research has revealed
that supportive interactions among employees are associ-
ated with employee perceptions of performance (Leggat,
Bartram, Casimir, & Stanton, 2010). In contrast, patient-
perceived quality of care may be influenced both by the
individualized interactions between employees and patients
as well as the environment in which patients are treated
(Aiken, Clarke, & Sloane, 2002; Greenslade & Jimmieson,
2011). These differences in care performance suggest two
distinct frameworks for how and why civility climate matters.
At the employee level, Bandura’s (1986) self-efficacy theory
posits that social influences provide information from which
individuals judge their capabilities, strength, and vulnera-
bility to dysfunction. That is, social aspects of the work
environment can strengthen individuals’ beliefs that they
can perform effectively. Extending this relationship to the
collectivelevel, we expect that civility policies, procedures,
and practices that support respect and acceptance, coop-
eration, supportive relationships, and fair conflict resolu-
tion among coworkers will collectively strengthen individuals’
beliefs that they can perform effectively. Elaborating on this
theory, we argue that in the health care context, where
employees are often engaged in complex interdependent
work, a civil social environment helps employees call on
one another’s expertise, energy, and competences. Civility
climate induces courteous and considerate behavior toward
other people and thereby enhances the quality of working
relationships and, in turn, perceived performance (e.g.,
Ortega, Sa
´nchez-Manzanares, Gil, & Rico, 2013). Indeed,
evidence from the health care context demonstrates that
the absence of civility is associated with lower work efforts,
less engagement in tasks and activities beyond job descrip-
tions, decreased voluntary efforts, and assistance to colleagues
(Pearson, Andersson, & Porath, 2000). Thus, this leads to
our first hypothesis.
H1a: Civility climate will be positively associated
with employee perceptions of care performance.
At the patientlevel, service climate researchers theorize
that employees treat customers in a manner similar to their
own treatment within an organization (Schneider, Wheeler,
& Cox, 1992). Robust evidence indicates that certain as-
pects of the interpersonal work climate, such as perceptions
of fairness, are positively associated with employee attitudes
and behaviors toward customers, which may in turn enhance
customer satisfaction (Schneider et al., 1992). Elaborating
on this evidence and adapting service climate research to the
health care setting, we argue thatastrongcivilityclimate
induces favorable employee attitudes and behaviors, which
affect employees’ interactions with patients. This effect is
particularly likely in the hospital setting because care services
are characterized by intense personal and unique relation-
ships between health care workers and patients. Indeed,
patient outcomes and perceived quality of care have been
associated with the environment in which patients are
treated as well as with employeeYpatient interactions
(Aiken et al., 2002; Greenslade & Jimmieson, 2011).
More specifically, prior research from the hospital context
indicated that high-quality provider relationships helped
care providers to develop effective relationships with their
patients (Gittell, 2002). Furthermore, nurses’ perceptions
of social interaction and trust among nurses have been
associated with the extent of customer-oriented prosocial
behavior and ultimately with patient satisfaction (Hsu,
Chang, Huang, & Chiang, 2011). Thus, both theory and
a small but growing body of empirical studies suggest that
Figure 1
Conceptual framework
Civility Climate and Hospital Performance 3
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a strong civility climate may induce employee behaviors
that can strengthen patients’ perceptions of care performance.
H1b: Civility climate will be positively associated
with patient perceptions of care performance.
Error Orientation Climate as a Mediator
Between Civility Climate and Performance
As a key dimension of safety climate, error orientation cli-
mate (Hofmann & Mark, 2006; Leape et al., 1998) can be
defined as the shared attitudinal and behavioral tendencies
relevant to handling and processing errors (e.g., Rybowiak,
Garst, Frese, & Batinic, 1999). A positive error orientation
climate is indicative of an environment that is supportive
of open dialogue and facilitates safer practices, whereas a
negative error orientation climate is characterized by dis-
trust and fear and results in unwillingness to assume respon-
sibility for mistakes (van Dyck, Frese, Baer, & Sonnentag,
2005). We conceive error orientation climate as a potential
mediator of the relationship between civility climate and
care performance for the following reasons: First, consistent
with the theory regarding foundational and specific cli-
mates, civility climate may form the necessary foundation
for developing a strongly shared error orientation. Strong
interpersonal relationships may be needed to facilitate a
constructive discussion of errors. Broadly, interpersonal as-
pects of the work environment are thought to affect em-
ployees’ attitudes and behaviors with regard to errors (Naveh
& Katz-Navon, 2014). For instance, Edmondson (2003)
found that the likelihood of hiding errors is associated with
employee perceptions of others’ disapproval and/or the neg-
ative personal consequences that employees might expe-
rience. Research evidence from the nursing context also
indicates how negative interpersonal behaviors, such as
bullying behaviors, affect the psychological/behavioral re-
sponses of nurses, such as their handling of medical errors
(Wright & Khatri, 2015).
Second, error orientation climate can affect hospital care
performance (Buljac-Samardºic et al., 2012; Leape et al.,
1998; Mark et al., 2008). Error orientation climate can
promote self-efficacy and thereby increasing beliefs that the
organization cares about improving patient care (Rybowiak
et al., 1999). A strong error orientation climate is critical to
reducing the consequences of negative errors (e.g., reduced
patient safety outcomes and hiding errors) and promoting
the benefits of positive errors (e.g., learning from errors and
knowledge building) in terms of the quality and safety of
patient care (Naveh & Katz-Navon, 2014; van Dyck et al.,
2005). Open-error communication and reporting are likely
to facilitate rapid error detection and handling, encourage
learning from errors, and enable specific safety improve-
ment interventions (Hofmann & Mark, 2006). By contrast,
research has identified weak error orientation as a con-
tributing factor when the number of medical errors is
unacceptably high and care performance is low (Mark
et al., 2008).
Compiling the theoretical and empirical evidence pres-
ented, we suggest that a strong civility climate should fa-
cilitate a strong error orientation climate and, in turn, care
performance in hospitals. Specifically, employees in an or-
ganization with a strong civility climate that signals a
personally nonthreatening and supportive interpersonal
environment should be more likely to freely speak up if
they observe something that may negatively affect patient
care or to question the decisions or actions of those with
more authority in situations involving patient care. Thus,
we hypothesize that the link between civility climate and
employee perceptions of care performance will be explained
by the intermediate mechanism of error orientation climate.
Nonetheless, we acknowledge that civility climate may
affect care performance through additional mechanisms
not explored here.
H2a: The relationship between civility climate and
employee perceptions of care performance will be
mediated by error orientation climate.
Error orientation climate may affect patients’ experi-
ences of care performance through two possible mecha-
nisms. First, employees’ attitudes toward the acceptance of
errors will improve quality of care because it prevents neg-
ative consequences of hiding errors and enhances positive
consequences of learning from errors. Although patients
might not be able to observe directly these quality-enhancing
learning processes resulting from a strong error orientation
climate, they still might experience increased quality of
care. However, the patient experience literature demon-
strates mixed results regarding patients’ ability to recognize
the handling of errors (Weissman et al., 2008). A recent
review noted that this ability of patients remains an open
question (Doyle, Lennox, & Bell, 2013). If patients are able
to recognize and distinguish between a strong or weak error
orientation climate displayed in their inpatient units, then
we would expect that a strong error orientation climate to
increase their beliefs that they will be informed in a trans-
parent way if an error occurs, which in turn will enhance
their perceptions of care performance. Second, Hofmann
and Mark (2006) theorized that error orientation may also
promote nurse responsiveness to patient concerns. Nurse
responsiveness is a factor that may be experienced directly
by both employees and patients, but likely in different
ways. Nurses may experience responsiveness as high-
quality care and may increase opportunities to identify or
prevent medical errors. In contrast, patients may experi-
ence responsiveness as interpersonally satisfying because
they view it as evidence that nurses care about them and
their well-being.
Thus, we anticipate that the link between civility cli-
mate and patient perceptions of care performance will be
4Health Care Management Review Month &2017
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explained by the intermediate mechanism of error orienta-
tion climate.
H2b: The relationship between civility climate and
patients’ perceptions of care performance will be
mediated by error orientation climate.
Methods
Data and Research Setting
As a research setting, we focused on the Veterans Health
Administration (VHA) within the U.S. Department of
Veterans Affairs. Providing subsidized medical care to almost
22 million veterans, the VHA is organized into regional
networks divided into 144 hospitals and more than 1,000
freestanding outpatient clinics at the time of the study. To
ensure the comparability of the respondents included in our
sample, we used patient and employee responses from acute
inpatient services. We included nursing employees, includ-
ing registered nurses and licensed practical nurses. Hospital
nurses provide and coordinate patient careand work closely
with a team of other skilled health care professionals. Thus,
nurses play an integral role in achieving high-quality health
care performance (Wright & Khatri, 2015). The study
was reviewed and approved by a VHA Institutional Re-
view Board.
Survey data were drawn from three sources collected in
2011. First, data on civility climate were obtained from the
VHA All Employee Survey restricting to our sample respon-
dents of interest (68% national response rate; N
sample
=
6,094). Second, data on error orientation climate and em-
ployees’ perceptions of care performance were collected from
a VHA National Center for Patient Safety survey (21%
response rate; N
sample
= 1,755). Third, data on patient
perceptions of care performance were obtained from the
VHA Survey of Healthcare Experiences of Patients (44%
response rate; N
sample
= 38,627). Responses to each survey
were aggregated at the facility level. The final data set con-
tained 123 unique VHA hospitals.
Variable Measurement
Civility climate. Civility climate was assessed with an
eight-item scale used in prior research (Leiter et al., 2011;
Osatuke et al., 2009) using a 5-point Likert scale ranging
from 1 (strongly disagree)to5(strongly agree) with good
reliability (!= .94). Employees assessed personal interest
and respect from coworkers, cooperation or teamwork in
the facility, fairness of conflict resolution, and the value
of individual differences by coworkers and supervisor within
a work group and across an organization. For each respondent,
civility climate was computed as the average of the eight
items for respondents who answered at least half of the
items in the scale.
Error orientation climate. Seven items adapted from
the comprehensive Rybowiak et al.’s (1999) Error Orien-
tation Questionnaire were used to measure error orienta-
tion climate on a 5-point Likert scale ranging from 1
(strongly disagree)to5(strongly agree) with good reliability
(!= .79). For example, employees assessed the extent to
which ‘‘Staff will freely speak up if they see something
that may negatively affect patient care’’ or ‘‘My co-workers
will not lose respect for me if they know I’ve made a mis-
take.’’ The seven items were aggregated to form a single
index of error orientation climate using a similar compu-
tation method as civility.
Employee perceptions of care performance. Seven
items focusing on quality and safety (e.g., Spence Laschinger,
Shamian, & Thomson, 2001) were used to measure employee
perceptions of care performance on a 5-point Likert scale
ranging from 1 (strongly disagree)to5(strongly agree) with
good reliability (!= .90). For example, nurses assessed the
extent to which ‘‘the facility has a reputation for high
quality performance’’ or ‘‘the patient safety processes and
procedures in this facility are better than the processes and
procedures found in other facilities.’’
For each respondent, a single index of care performance
was computed as the average of the seven items when at
least half of the items were answered.
Patient perceptions of care performance. A single
item was used to measure overall patient perceptions of
care performance. Patients were ask to indicate on a 0Y10
scale, where 0 is the worst hospital possible and 10 is the best
hospital possible, what number they would use to rate this
hospital during their stay. Because patient characteristics
have been associated with their ratings oncare experiences
(Xiao & Barber, 2008), we computed the residualized value
for patient experience accounting for characteristics of
health status, age, gender, marital status, and race/ethnicity.
Then, scores were aggregated to the facility level.
Control variables. Three variables were used to account
for potential influences of facility-level factors on patient
and employee perceptions of care performance (Singer et al.,
2009; van Dyck et al., 2005). First, facility size was measured
by total full-time equivalent employee values for nurses.
Second, we included staffing ratios, defined as the number
of nursing hours per patient day. Both measures were
obtained from internal VHA administrative sources. Third,
we accounted for whether a hospital was located in an
urban or rural metropolitan statistical area (using values of 1 =
urban/0 = rural).
Aggregation Statistic
Intraclass correlation coefficients, ICC(1) and ICC(2), and
within-group agreement (rwg) provided sufficient empirical
Civility Climate and Hospital Performance 5
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support for aggregating the scores for our variables at the
facility level (James, Demaree, & Wolf, 1984). Across all
variables in our study, the average ICC(1) value was .10,
ranging from .08 to .13. The average ICC(2) was .68, rang-
ing from .61 to .79. The rwg values ranged from .79 to .90.
Taken together, our statistics provided sufficient empirical
support for aggregating the scores for our variables at the
facility level.
Analytical Strategy
Our approach to analysis was first to assess the associations
of civility climate and error orientation climate with em-
ployees’ perceptions of care performance (Models 1 and 2)
and with patients’ perceptions of care performance (Models
4 and 5). We then tested models with both civility climate
and error orientation climate included in the same model
(Models 3 and 6). To test the direct effects of civility cli-
mate (Hypotheses 1a and 1b), we performed ordinary least
squares regressions using SAS version 9.2. Mediation was
tested using the PROCESS macro developed by Hayes (2013)
for SPSS Statistics, Version 21. The PROCESS macro provides
95% bootstrap confidence intervals around the indirect effect
of civility climate as mediated through error orientation
climate (H2a and H2b). The bootstrapping procedure is
superior to traditional mediation methods because it allows
a direct estimation of standard errors for indirect effects,
whereas other methods require the use of formulas that have
been criticized in recent years (Hayes, 2013).
Results
Descriptive statistics and correlations of the study variables
are presented in Table 1.
Table 2 shows the direct effects of civility climate and
error orientation climate on employees’ perception of care
performance (Models 1Y3) and patients’ perceptions of care
performance (Models 4Y6). Civility climate was significantly
related to employee care performance perceptions (Model 1:
"= 0.332, pG.01), supporting Hypothesis 1a, and to patient
perceptions of care performance (Model 4: "=0.286,pG
.01), supporting Hypothesis 1b.
To test H2a and H2b, we analyzed the mediating effects
of error orientation climate on the relationship between
civility climate and perceptions of care performance. The
results indicated that civility climate had a positive direct
effect on error orientation climate ("= 0.377, pG.01), and
error orientation climate was positively related to both
employee perceptions of care performance (Model 2: "=
0.644, pG.01) and patient perceptions of care performance
(Model 5: "= 0.219, p= .04). Mediation hypotheses are
supported if a significant indirect effect is observed between
civility and care performance through the intermediate
influence of error orientation climate. We tested indirect
effects using the bootstrap method (Hayes, 2013). Applying
the PROCESSmacro developed by Hayes (2013) for SPSS,
we obtained 95% bootstrap confidence intervals around
the indirect effect to correct for biased standard errors. For
the employee model, the bias-corrected confidence interval
for error orientation climate (0.20, 0.83) does not contain
zero; hence, the indirect effect is significantly different from
zero. These results support Hypothesis 2a, which posits that
the positive association between civility climate and em-
ployee perceptions of care performance is mediated by error
orientation climate. In contrast, for the patient model, the
bias-corrected confidence interval for error orientation cli-
mate (j0.04, 0.15) does contain zero. Thus, H2b is rejected
because we cannot state that the indirect effect is signif-
icantly different from zero.
Discussion
This study demonstrated that civility climate is associated
with both employee and patient perceptions of care per-
formance. Error orientation climate was found to mediate
the association between civility climate and employee
Table 1
Means, standard deviations, and correlations
Variables Mean SD 1234567
1 Civility climate 3.54 0.34 1.00
2 Error orientation climate 3.49 0.23 .39*** 1.00
3 Employees’ perceptions of care performance 3.57 0.30 .36*** .67*** 1.00
4 Patients’ perceptions of care performance 8.64 0.28 .28** .20* .41*** 1.00
5 Facility size 70.00 23.45 .11 .09 .19* j.08 1.00
6 Staffing 10.55 5.02 .01 .07 .06 .19* j.20* 1.00
7 Location (urban) 0.78 0.41 .08 .04 .06 j.17* .38*** j.15 1.00
Note. N = 123.
*pG.10. **pG.01. ***pG.001.
6Health Care Management Review Month &2017
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perceptions of care performance. This result suggests that
error orientation climate, a specific climate and key aspect
of the safety climate, helps to explain how civility climate, a
foundational climate, is translated into increased employee
perceptions of care performance. By contrast, for patients’
perceptions of care performance, both civility climate and
error orientation climate had main effects, but only civility
climate was associated with patient care performance when
both variables were included in the model; the mediating
influence of error orientation climate was not supported.
This study contributes to the health care literature in
several ways. First, by focusing on civility climate, this
study contributes to the nascent body of research on positive
interpersonal aspects of the work environment (Laschinger
& Read, 2016; Leiter et al., 2011; Osatuke et al., 2009).
Despite evidence from the health care literature on the
negative relationship between incivility and both individual
and organizational performance outcomesVsuch as increased
turnover, reduced individual well-being, lower job satisfaction
and performance, and lower self-reported team effectiveness
(e.g., Wright & Khatri, 2015)Vresearch has fallen short in
investigating whether and how hospital care performance
might improve by creating and strengthening a positive
interpersonal work climate. Our study highlights civility
climate as an important success factor in the hospital ser-
vice context.
Second, our study contributes to the literature by explor-
ing intermediate processes through which perceptions of
civility climate are linked to hospital care performance. De-
spite a growing body of research highlighting the important
role of organizational climate for ensuring high quality and
safety in patient care (e.g., Singer et al., 2009), limited re-
search has sought to identify mediators of the climateY
performance link in the hospital context. By linking civility
climate, a foundational climate, to error orientation climate,
aspecificclimate,weprovidenew theoretical insights on the
interrelation between foundational and specific climate di-
mensions. Specifically, we highlight how the work environ-
ment (civility climate) affects employees’ shared perceptions
of attitudinal and behavioral reactions to handling errors
(error orientation climate). This insight is especially infor-
mative given the persistent problems associated with hos-
pital employees underreporting adverse events as well as the
resulting negative patient consequences despite increasing
investment in error reporting systems (e.g., Naveh & Katz-
Navon, 2014). Considering that reporting systems work
only if employees are willing to use these systems, our study
suggests that much benefit can be gained by fostering a
civility climate that facilitates error reporting. More pre-
cisely, our results suggest that a strong civility climate has
the potential to indirectly affect hospital care performance
by creating an atmosphere in which individuals are willing
to reveal, discuss, and learn from their own mistakes.
Third, by accounting for the multidimensionality in hos-
pital care performance, our findings indicate that a strong
civility climate not only benefits employees but also im-
proves patient perceptions of care performance. The results
suggest that patients notice how employees interact with
one another. Hospitals that support these civil interactionsV
particularly in terms of respect and acceptance, cooperation,
supportive relationships, and fair conflict resolutionVmay
have a significant influence on patient perceptions of care
performance. In contrast to our expectations, we did not
find that error orientation climate mediated the association
between civility climate and patient perceptions of care
performance. Error orientation climate had a smaller asso-
ciation with patient perceptions of care performance than
with employee perceptions of care performance. This finding
Table 2
Ordinary least squares regression results
Variable
Perceptions of care performance
Employees Patients (adjusted)
Model 1 Model 2 Model 3 Model 4 Model 5 Model 6
Civility climate 0.332*** 0.106
ns
0.286*** 0.216**
Error orientation climate 0.644*** 0.605*** 0.219** 0.138
ns
Control variables
Facility size 0.178* 0.157* 0.148* 0.163* 0.017
ns
0.174*
Staffing 0.060
ns
0.011
ns
0.013
ns
j0.024
ns
0.169
ns
j0.001
ns
Location (urban) j0.011
ns
j0.023
ns
j0.018
ns
j0.173* j0.125
ns
j0.114
ns
Adjusted R
2
0.16 0.43 0.46 0.15 0.11 0.15
Note. N = 123. Standardized regression coefficients are shown. Models 1Y3: Regression results show the link between civility climate and
employees’ perception of care performance as mediated by error orientation climate. Models 4Y6: Regression results show the link between
civility climate and adjusted patients’ perception of care performance as mediated by error orientation climate. ns = not significant.
*pG.1. **pG.05. ***pG.01.
Civility Climate and Hospital Performance 7
Copyright © 2017 Wolters Kluwer Health | Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
may suggest that patients have a limited ability to detect
behaviors related to error orientation climate. Nurses’ be-
haviors relevant to handling errors might be less observable
for patients due to information asymmetry and the lack of
detailed medical knowledge. Furthermore, patients may be
more likely to experience the outcome of error orientation
climate, such as actual errors, than whether dimensions of
error orientation, such aswhether staff will freely speak up if
they see something, as these discussions may happen out-
side of patient observations. Any strong interpersonal be-
haviors that patients observe may thus be attributable only
to civility climate, not to error orientation climate.
Although our study offers a number of important con-
tributions, it does have limitations, each of which offers
avenues for future research. The first set of limitations relate
to the measurement and selection of the variables used in
our study. In particular, we focused on employees’ and
patients’ perceptions of care performance as anindicator of
hospital care performance. Although patient care percep-
tions are a relevant performance outcome in the hospital
setting (e.g., Spence Laschinger et al., 2001), future studies
could extend our research by replicating our model using
objective external hospital performance data, such as ad-
verse event reporting and safety incident rates. In addition,
we focus on the specific occupational group of nurses. Given
that occupational groups in hospitals are likely to differ in
their occupational values, work structure, responsibilities,
professional education, and culture, future studies could
examine whether civility climate produces the same degree
of positive effects on occupational groups other than
nurses. Further research is needed to identify how and
under which conditions civility climate may influence
interprofessional relations, such as relations between nurses
and doctors. In addition, none of our data measured how
patients perceive their interaction with employees. Through
the direct measurement of patient perceptions of their in-
teraction with bedside hospital staff, further research
might empirically analyze additional mediating mech-
anisms, such as patientYprovider interactions through
which civility climate may improve care performance from
the patient perspective.
The second limitation concerns the facility level of anal-
ysis used in this study. Our research design linked several
anonymous surveys by a common facility identifier. This
limited our ability to test more complex relationships across
different levels of analysis. Considering that climate percep-
tions might be influenced by team structure, professional
norms, prior working experience, or leadership, researchers
should make allowance for the coexistence of multiple and
heterogeneous civility climate perceptions within hospital
facilities. Future research is needed to combine different
levels of analysis (e.g., work group, team, and facility) and
investigate multilevel research questions.
Third, our observational and cross-sectional research
design limits the extent to which causeYeffect relation-
ships can be inferred from the findings. For instance, our
design prevents us from drawing conclusions on whether
civility climate, a foundational climate, affects error orien-
tation climate, a specific climate, or vice versa. The liter-
ature on civility climate in hospitals would benefit from
interventional or longitudinal studies that are better equipped
to make causal statements and address the possibility of reverse
causality. Finally, this study was conducted in the specific
context of the VA Healthcare System, a federally adminis-
tered system that differs from other health care systems in ways
that may limit the generalizability of the findings. Although
our findings should be applicable to settings with similar
health care system designs, hospital management practices,
and employment structures, further research should test
whether the results can be replicated in private hospitals,
other health systems (e.g., U.K. National Health Service),
and different service sectors.
Implications for Practice
Despite its limitations, this study provides valuable insights
and useful information for hospital managers. Overall, our
findings point to the importance of positive interpersonal
work environments as a powerful tool for ensuring and
improving both employees’ and patients’ perceptions of
care, which constitute key success factors in the increas-
ingly competitive hospital market. With employee percep-
tions of care performance serving as an important predictor
of job satisfaction, well-being, motivation, and organiza-
tional commitment (Spence Laschinger, Grau, Finegan, &
Wilk, 2012), a strong civility climate and the resulting im-
proved care perceptions might counteract human resource-
related challenges, such as high turnover rates and increasing
workforce shortages among clinical staff. Interventions to
establish a strong civility climate could include workshops,
structured exercises, discussion points, and facilitation points
to promote more civil interactions among employees (Osatuke
et al., 2009). For more detailed information on interven-
tions to enhance civility in the hospital work context, we
refer to the work by Osatuke et al. (2009). The results
indicate that investing in interventions that establish both
a strong civility climate and strong error orientation climate
may also improve patient perceptions of care performance.
Patients’ perceptions of care performance are an indicator
of care quality and are believed to be an important con-
tributor to other health outcomes (e.g., continued use of
health services; Greenslade & Jimmieson, 2011). Building
on our results, hospital managers are well advised to foster a
civility climate, which can also support people speaking up
about errors, prevent incidents from occurring, and reduce
the number of ‘‘near misses’’ in health care. Particularly in
consideration of the high costs of errors and adverse events
in health care, it is of utmost importance to detect factors
that may prevent errors.
8Health Care Management Review Month &2017
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Conclusions
Our study tested a model to determine how civility climate
affects care performance as perceived by both employees
and patients. The key innovation of this study was in the
conceptual and theoretical links between civility climate,
error orientation climate, and care performance as expe-
rienced by both employees and patients. Our analyses
highlighted the importance of a strong civility climate for
ensuring that both employees and patients perceive high-
quality care in hospitals. The results of these analyses have
important implications for civility climate interventions as
means to improve care performance. The insights may further
stimulate discussions regarding the importance of civility
climate for both patient- and employee-related outcomes.
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Working environments that are both civil and safe are good for business and employee well-being. Civility has been empirically linked to such important outcomes as organizational performance and individuals' positive work-related attitudes, yet research relating civility to safety is lacking. In this study, we link perceptions of civility norms to perceptions of safety climate and safety outcomes. Drawing on social exchange theory, we proposed and tested a model in 2 samples wherein civility norms indirectly relate to safety outcomes through associations with various safety climate facets. Our results supported direct relationships between civility and management safety climate and coworker safety climate. Additionally, indirect effects of civility norms on unsafe behaviors and injuries were observed. Indirect effects of civility norms on unsafe behaviors were observed through coworker safety climate and work-safety tension. Indirect effects of civility norms on injuries were observed through management safety climate and work-safety tension for full-time employees, although these effects did not hold for part-time employees. This study provides initial evidence that researchers and practitioners may want to look beyond safety climate to civility norms to more comprehensively understand the origins of unsafe behaviors and injuries and to develop appropriate preventive interventions. (PsycINFO Database Record (c) 2014 APA, all rights reserved).
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OBJECTIVE: This study examined the influence of authentic leadership, person-job fit with 6 areas of worklife, and civility norms on coworker incivility and burnout among new graduate nurses. BACKGROUND: New graduate nurses report experiencing high levels of workplace incivility from coworkers, which has been found to negatively impact their job and career satisfaction and increase their intention to leave. The role of civility norms in preventing burnout and subsequent exposure to incivility from coworkers has yet to be examined among new graduate nurses. METHODS: A cross-sectional mail survey of 993 new graduate nurses across Canada was conducted. RESULTS: The results supported the hypothesized relationships between study variables. CONCLUSIONS: Civility norms play a key role in preventing early career burnout and coworker incivility experienced by new graduate nurses. Leaders can influence civility norms by engaging in authentic leadership behaviors and optimizing person-job fit.
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The amount and frequency of change affecting the health care industry makes management of a work environment particularly challenging for nursing leaders Numerous studies are discussed that explore the influence of organization behavior and issues of staff perception on measurable outcomes such as nurse retention and patient satisfaction. The authors surveyed staff nurses using instruments that assess their perceptions of (a) autonomy, control, and physician relationships; (b) faith and confidence in peers and managers; (c) emotional exhaustion; (d) job satisfaction; and (e) the quality of patient care. The findings suggest that perceived autonomy, control, and physician relationships influence the trust, job satisfaction and perceived quality of patient care. Professional practice models may provide a means to achieve positive staff perceptions of autonomy and control while managing the realities of flattening organizational structures.
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Convergent evidence from the diverse lines of research reported in the present special issue of this journal attests to the explanatory and predictive generality of self-efficacy theory. This commentary addresses itself to conceptual and empirical issues concerning the nature and function of self-percepts of efficacy.
Article
Background: Hospitals routinely survey patients about the quality of care they receive, but little is known about whether patient interviews can detect adverse events that medical record reviews do not. Objective: To compare adverse events reported in postdischarge patient interviews with adverse events detected by medical record review. Design: Random sample survey. Setting: Massachusetts, 2003. Patients: Recently hospitalized adults. Measurements: By using parallel methods, physicians reviewed postdischarge interviews and medical records to classify hospital adverse events. Results: Among 998 study patients, 23% had at least 1 adverse event detected by an interview and 11% had at least 1 adverse event identified by record review. The K statistic showed relatively poor agreement between interviews and medical records for occurrence of any type of adverse event (K= 0.20 [95% Cl, 0.03 to 0.27]) and somewhat better agreement between interviews and medical records for life-threatening or serious events (K= = 0.33 [Cl, 0.20 to 0.45]). Record review identified 11 serious, preventable events (1.1% of patients). Interviews identified an additional 21 serious and preventable events that were not documented in the medical record, including 12 predischarge events and 9 postdischarge events, in which symptoms occurred after the patient left the hospital. Limitations: Patients had to be healthy enough to be interviewed. Delay in reaching patients (6 to 12 months after discharge) may have resulted in poor recall of events during the hospital stay. Conclusion: Patients report many events that are not documented in the medical record; some are serious and preventable. Hospitals should consider monitoring patient safety by adding questions about adverse events to postdischarge interviews.
Article
In 1995, a series of highly publicized medical incidents with serious adverse patient consequences awakened public and professional interest in safety in health care. In response to this increased awareness and recognizing that health care could learn much about safety from other industries, in October 1996, the American Association for the Advancement of Science, the American Medical Association (AMA), and the Joint Commission on Accreditation of Healthcare Organizations (JCAHO) joined with the Annenberg Center for Health Sciences to convene the first multidisciplinary conference on errors in health care.
Article
Background: Although patient handoffs have been extensively studied, they continue to be problematic. Studies have shown poor handoffs are associated with increased costs, morbidity, and mortality. No prior research compared perceptions of management and clinical staff regarding handoffs. Purpose: Our aims were (a) to determine whether perceptions of organizational factors that can influence patient safety are positively associated with perceptions of successful patient handoffs, (b) to identify organizational factors that have the greatest influence on perceptions of successful handoffs, and (c) to determine whether associations between perceptions of these factors and successful handoffs differ for management and clinical staff. Methodology/approach: A total of 515,637 respondents from 1,052 hospitals completed the Hospital Survey on Patient Safety Culture that assessed perceptions about organizational factors that influence patient safety. Using weighted least squares multiple regression, we tested seven organizational factors as predictors of successful handoffs. We fit three separate models using data collected from (a) all staff, (b) management only, and (c) clinical staff only. Findings: We found that perceived teamwork across units was the most significant predictor of perceived successful handoffs. Perceptions of staffing and management support for safety were also significantly associated with perceived successful handoffs for both management and clinical staff. For management respondents, perceptions of organizational learning or continuous improvement had a significant positive association with perceived successful handoffs, whereas the association was negative for clinical staff. Perceived communication openness had a significant association only among clinical staff. Practice implications: Hospitals should prioritize teamwork across units and strive to improve communication across the organization in efforts to improve handoffs. In addition, hospitals should ensure sufficient staffing and management support for patient safety. Different perceptions between management and clinical staff with respect to the importance of organizational learning are noteworthy and merit additional study.
Article
AIM:: The aim of this article is to examine the relationship between three types of bullying (person-related, work-related, and physically intimidating) with two types of outcomes (psychological/behavioral responses of nurses and medical errors). In addition, it investigates if the three types of bullying behaviors vary with age or gender of nurses and if the extent of bullying varies across different facilities in an institution. Nurses play an integral role in achieving safe and effective health care. To ensure nurses are functioning at their optimal level, health care organizations need to reduce negative components that impact nurses' job performance and their mental and physical health. Mitigating bullying from the workplace may be necessary to create and maintain a high-performing, caring, and safe hospital culture. Using an internal e-mail system, an e-mail requesting the participants to complete the questionnaire on Survey Monkey was sent to a sample of 1,078 nurses employed across three facilities at a university hospital system in Midwest. Two hundred forty-one completed questionnaires were received with a response rate of 23%. Bullying was measured utilizing the Negative Acts Questionnaire-Revised (NAQ-R). Outcomes (psychological/behavioral responses of nurses and medical errors) were measured using Rosenstein and O'Daniel's (2008) modified scales. Person-related bullying showed significant positive relationships with psychological/behavioral responses and medical errors. Work-related bullying showed a significant positive relationship with psychological/behavioral responses, but not with medical errors. Physically intimidating bullying did not show a significant relationship to either outcome. Whereas person-related bullying was found to be negatively associated with age of nurses, physically intimidating bullying was positively associated with age. Male nurses experienced higher work-related bullying than female nurses. Findings from this study suggest that bullying behaviors exist and affect psychological/behavioral responses of nurses such as stress and anxiety and medical errors. Health care organizations should identify bullying behaviors and implement bullying prevention strategies to reduce those behaviors and the adverse effects that they may have on psychological/behavioral responses of nurses and medical errors.